On the 50th anniversary of Sir Edmund Hillary and Tensing Norgay's historic trip to the summit of Mount Everest, a team of German medical scientists from the University of Giessen attached themselves to a group of mountaineers looking to replicate Hillary and Norgay's success. Amongst the usual types of equipment packed for such a trek was one unusual one - 20-pound ultrasound system. The Siemens Acuson Cypress was a key tool for the scientists to investigate changes in cardiac performance and lung function at extreme altitudes during an expedition to the summit of the world's highest mountain.
Over the past five years, rapid advances in ultrasound technology have made these systems more compact while increasing their ability to handle complex applications and provide greater image quality. Ground-breaking studies like the one performed on Mount Everest are now possible in the field due to the technology's portability. Even within the hospital, clinic, or private practice, great clinical feats are being accomplished every day in Ob/gyn, pediatrics, emergency medicine, and radiology.
Patient-centric care is one of the great benefits of portable ultrasound technology. For David P. Bahner, MD, assistant professor and director of Ultrasound Department of Emergency Medicine at Ohio State University, clinicians should strive to make the patient the focal point of care rather than transporting patients to and from various departments for testing.
"With [GE Healthcare's] LOGIQ Book XP, we are able to acquire excellent images faster than ever before - right in the ER - and transmit them wirelessly to the hospital network. These advances in portability and connectivity will further increase our mobility, streamline our clinical workflow and allow us to apply new diagnostic tools like ultrasound [systems] across all patient-care areas of the hospital."
The LOGIQ Book can store up to 30,000 high-quality images in a standard DICOM based format. Wireless features are available by plugging a PCMCIA card into the back of the 10-pound system. Images from the patient are captured in the LOGIQ Book, frozen, and at the touch of a program print key, either wirelessly uploaded to PACS, to a colorless or black-and-white printer, or downloaded straight to the hard drive. Bahner sees networked images as the wave of the future; he and his staff have configured the LOGIQ Book to communicate wirelessly with the facility's PACS. Once the patient has been scanned, his or her demographics are downloaded as well. This information is then uploaded to the network and patient data can be accessed and reviewed by anyone with the proper security clearance.
Learning the ropes
Yet, widespread acceptance of this new technology is hampered by what Bahner describes as "technophobia." Proper training is a barrier to use. To address this issue, Bahner has created an ultrasound academy as a centralized area to train all users of ultrasound, whether they are students, residents or sonographers. "There is a contingent that is willing to overcome [their technophobia], especially in the emergency medicine community. We have embraced the technology because if you can put the hours into understanding the knobs and start playing with the equipment, you can get more proficient. It can give you clinical images that can help in your medical decision-making." He sees motivated learners as a necessary element in broadening the appeal of ultrasound technology.
As for the future of portable and hand-held ultrasound, Bahner has noticed a rise in use by internal medicine in the critical-care environment. With the recent passage of House resolution SAVE (Screening for Aortic Aneurysm Very Efficiently), the need for a rapid diagnostic tool becomes more prevalent. The use of these systems is almost unlimited. Anytime a physician needs to look into the body or guide an intervention, ultrasound is an asset. Other areas in which the technology is finding more and more usage is in the ER for assessing serious bleeds that need quick answers. Or in pain therapy, a hand-held ultrasound system can be used to find the nerve that needs to be blocked and an anesthetic can be injected locally, avoiding general anesthesia.
Ultrasound on the go
Bringing the technology to the patient also is an important part of how sonographer Alex Cruz, owner/president of Southeast Medical Imaging, uses his Biosound Esaote MyLab. In addition to running his own lab, Cruz also performs mobile ultrasound exams bringing the equipment to private homes and doctors' offices. He and his sonographers perform a variety of applications using the MyLab, from echocardiology to vascular, small parts, and abdominal imaging.
MyLab weighs less than 20 pounds, and Cruz says he's seen a positive impact on his business due to the portability of the unit. It is more fuel-efficient than having to carry around a full size unit in a van. He's also no longer limited in who he can hire, which is a concern with much heavier and less portable units that require more strength to move in and out of remote locations. Data from the portable unit can be uploaded to PACS via a USB port. Images can be transmitted from any location with high-speed internet access.
Premium features with portability
Keith Holub, president of American Diagnostics, a company that provides ultrasound services to physicians' offices, has used portable ultrasound systems by SonoSite, GE, and Zonare. The demands of his job create a special need for highly portable systems that deliver high-quality images. A system needs to be lightweight enough to be taken from place to place. In the case of Holub's business, this includes clinics and offices that don't have the volume to justify spending capital on their own system or to hire a professional sonographer.
For Holub, portable ultrasound offers unrivaled image quality. Yet, there is still room for improvement, especially in achieving what he refers to as the "gold standard" of ultrasound: the ability to see the image clearly and to have the patient scan done quickly and efficiently in a reasonably priced unit.
Zonare came out with all the improvements he was looking for in a portable: a multi-faceted system with high-quality imaging. When undocked from its cart, it's a lightweight 5.5 pounds with all the features and functions of a premium ultrasound system. He compares it to a basic FM radio or a mini stereo system. "You still get the nice size, but you also get the premium sounds all in one small package," Holub says. "That's where Zonare really allows you to excel by giving you the best of both worlds: small size and high quality [images]. There is finally a product that is going more to the needs of taking the portable product and bringing it into the premium world."
Plenty of storage
One feature Holub finds indispensable is the ability to store up to 2 GB of scan data onto a compact flash drive. Over the course of a typical day - they move from one physician's office to another, Holub's technologists might scan up 18 patients, multiply that number by 30 to 35 images for each patient and it adds up to a lot of important information that needs to be stored in a safe place. "I can have someone take pictures all day and then come back and download them into our server. If we were in one place, we'd have a direct link. But we're not. The compact flash solves all my problems of how to store a day's work."
E. A. Lyons, MD, professor of Radiology, Ob/gyn, and Anatomy at the University of Manitoba, expresses a similar admiration for the ease of uploading important data from his portable Zonare to a PACS. He finds multiple uses for his portable in both the ER and in the departments. The Zonare is used in applications ranging from portable needling and aspiration to monitoring procedures in the OR and to kidney biopsies.
It is an indispensable training tool and Lyons has introduced the new technology into the medical school's curriculum: first year anatomy students get an up-close look at what the technology can do. In his gross anatomy lab, Lyons sets a cadaver on one examining table and a student on another. He scans the student with the system, pointing out different features of internal anatomy on the screen and then shows the students how it appears in a real body via the cadaver. He's noticed that this approach makes it easier for students to appreciate what's going on; they can see how the technology works and also how it relates to anatomy in the flesh.
Far and away
Taking the ultrasound system to the patient can sometimes be more challenging than walking it down the hall or across a hospital campus. Siemens' Cypress system has been carried around the world, from the Caribbean to the remote reaches of Mongolia, and used in clinics at these locations to scan children with suspected congenital heart disease. The Caribbean Heart Menders organization is sponsoring at least four medical missions in 2005 to treat and diagnose children with congenital heart defects in several developing countries throughout the Caribbean, including Trinidad, Haiti, the Dominican Republic, and Jamaica. The team of pediatric cardiothoracic surgeons, pediatric cardiologists, anesthesiologists, perfusion technicians, and specialized cardiac intensive care nurses will travel with the Cypress system to the Dominican Republic and perform 10 to 15 surgeries, as well as a number of interventional cardiac catheterizations.
"To date, we have been using whatever technology is available in the facilities, which consists of very old machines geared for adult studies, and often without appropriate probes for children," says Alvaro Galindo, MD, chairman of Caribbean Heart Menders Association and associate professor, director of the Pediatric Cardiac Cath-eterization Laboratory at the University of Miami School of Medicine.
That meant Galindo and his team strained to define anatomy prior to surgery, which could result in dire consequences. "With the Cypress cardiovascular system and the excellent image quality, we can perform high-quality studies accurately on young children and make more confident diagnoses," continues Galindo.
The Cypress features KinetDx ultrasound PACS to manage patient data. Using the Cypress' link and viewer software, the system can directly link its data output into any computer into which program is loaded. Images and studies can be reviewed at a later time or burned to CD. The unit's 40-gigabyte (GB) hard drive is capable of holding between 30,000 and 40,000 images.
In bringing portable ultrasound technology to new environments, medical professionals have been able to conduct in-depth experiments directly in the field. But it is not just the capacity for collecting data that makes hand-held ultrasound an invaluable research tool. Once the data have been collected, these systems allow a researcher to analyze the information on the spot to quickly detect trends or patterns.
Terason Ultrasound Systems was selected as the screening system for a joint U.S.-Ukraine-Belarus study project, directed by Ihor Masnyk, MD, of the National Cancer Institute. The study is a longitudinal surveillance project involving a sample population of more than 20,000 that is designed to assess changes in the thyroid glands of persons exposed to radioactive materials released as a consequence of the 1986 Chernobyl Nuclear Power Plant accident. To date, the Ukrainian and Belarusian centers have performed more than 5,000 field exams with the Terason units, storing more than 300 GB of image data. Physicians have reported that the systems' ability to store and later review image loops has been of critical importance when clinical questions arise.
On the battlefield
One of the most challenging environments in which portable ultrasounds are used is in combat. Flexibility and mobility are key requirements for a military medical unit to keep up with moving combat units on the modern battlefield. According to Col. Thomas Rozanski, MD, a urologist in the U.S Marine Corps, portable sonography markedly expanded the diagnostic capabilities of his forward deployed combat support hospital during Operation Iraqi Freedom.
More than 400 ultrasound studies were performed during the first six months of hospital operations in Iraq. Portable systems were used in multiple applications including: renal evaluations, focused assessment with sonography in trauma (FAST) examinations, ocular globe imaging and shoulder varicosities. The most widely used system was the SonoSite 180 Plus, chosen for its high-degree of portability - it weighs 5.5 pounds - and for its high-resolution color images in both two-dimensional and Doppler imaging. Images can be downloaded to a laptop computer or stored on compact disk. Stored images can then be included in patient records and efficiently sent with patients, whether they were returned to duty or evacuated to another treatment facility.
Rozanski credits portable sonography with augmenting the diagnostic capacity of combat medical professionals, "Portable sonography is a rapid, reliable, and markedly beneficial to deployed medical units. The ability to provide quality care to soldiers and therefore 'to preserve the fighting strength' supports the use of quality, portable, useful technology on the battlefield."
No less demanding an environment for portable ultrasounds systems is a busy trauma department. As patients are brought into the trauma bay, the ability to give a fast and focused exam is a critical first step in giving an accurate diagnosis. Chris Bandy, MD, head of the Trauma Department at Stormont Vail Health Care in Topeka, Kan., uses a SonoSite Titan to check trauma patients for intra-abdominal bleeding. The exam is non-invasive and quick, giving a four-view of the abdominal region. Plus, bringing the exam bedside alleviates further stress in moving the patients.
Bandy's department uses two of the highly portable Titan units in trauma and ICU. SonoSite's software is installed onto both a laptop and desktop computer, allowing him to upload and archive images from the Titan into the hospital's database.
And what about training? That took about two hours. "If you can use a laptop, you can use [the SonoSite Titan]," Bandy says.
As for the future of portable ultrasound systems, many health professionals see them becoming as commonplace as the stethoscope. The reduced size and ease of use features make hand-held ultrasound an important tool for the physician looking to conduct studies inside and outside the clinic or hospital setting. Thanks to the continued miniaturization of technology and increasing computing speed, portables will continue to decrease in size and weight while flexing new capabilities. The richness of new product offerings will be many.